BACKGROUND:
In systems with public health insurance, coverage decisions should reflect social values. Deliberation among stakeholders could achieve this goal, but rarely involves patients and citizens directly.

OBJECTIVES:
This study aimed at evaluating the acceptability, and the perceived benefits and risks, of public and patient involvement (PPI) in coverage decision making to Belgian stakeholders.

METHODS:
A two-round Delphi survey was conducted among all stakeholder groups. The survey was constructed on the basis of interviews with 10 key stakeholders and a review of the literature on participation models. Consensus was defined as 65% or more of the respondents agreeing with a statement and less than 15% disagreeing. Eighty stakeholders participated in both rounds. They were defined as the Delphi panel.

RESULTS:
Belgian stakeholders are open toward PPI in coverage decision processes. Benefits are expected to exceed risks. The preferred model for involvement is to consult citizens or patients, within the existing decision-making structures and at specific milestones in the process. Consulting citizens and patients is a higher level of involvement than merely informing them and a lower level than letting them participate actively. Consultation involves asking nonbinding advice on (parts of) the decision problem. According to the Delphi panel, the benefits of PPI could be increasing awareness among members of the general public and patients about the challenges and costs of health care, and enriched decision processes with expertise by experience from patients. Potential risks include subjectivity, insufficient resources to participate and weigh on the process, difficulties in finding effective ways to express a collective opinion, the risk of manipulation, and lobbying or power games of other stakeholders.

CONCLUSIONS:
PPI in coverage decision-making processes is acceptable to Belgian stakeholders, be it in different ways for different types of decisions. Benefits are expected to outweigh risks.

"How can individuals best be encouraged to take more responsibility for their well-being and their environment or to behave more ethically in their business transactions? Across the world, governments are showing a growing interest in using behavioural economic research to inform the design of nudges which, some suggest, might encourage citizens to adopt beneficial patterns of behaviour. In this fascinating collection, leading academic economists, psychologists and philosophers reflect on how behavioural economic findings can be used to help inform the design of policy initiatives in the areas of health, education, the environment, personal finances and worker remuneration. Each chapter is accompanied by a shorter 'response' that provides critical commentary and an alternative perspective. This accessible book will interest academic researchers, graduate students and policy-makers across a range of disciplinary perspectives"--

OBJECTIVE: This article aims to calculate the impact of orphan drugs on the Belgian drug budget in 2008 and to forecast its impact over the following 5 years. METHOD: The 2008 budget impact was calculated by triangulating information derived from multiple Belgian data sources. The 2008-2013 budget impact analysis was based on three scenarios reflecting different levels of growth in the number of registered orphan drugs in the European Union, the number of drugs reimbursed in Belgium, and the average annual cost per patient per drug in Belgium. RESULTS: The orphan drug budget impact amounted to euro66.2 million (or 5% of the Belgian hospital drug budget) in 2008. The impact would increase to euro130-204 million in 2013, depending on the scenario. CONCLUSIONS: This static analysis measured orphan drug costs only, assuming that other components of health expenditure do not change over time. The analysis showed that the budget impact of orphan drugs in Belgium is substantial and rising, thereby putting pressure on total drug expenditure. Policy options to address the rising budget impact include pricing linked to return on investment, risk-sharing arrangements and re-appraisal of orphan drug status if additional indications are approved.

This report examines how countries perform in their ability to prevent, manage and treat cardiovascular disease (CVD) and diabetes. The last 50 years have witnessed remarkable improvements in CVD outcomes. Since 1960, overall CVD mortality rates have fallen by over 60%, but these improvements are not evenly spread across OECD countries, and the rising prevalence of diabetes and obesity are threatening to offset gains.

This report examines how OECD countries deliver the programmes and services related to CVD and diabetes. It considers how countries have used available health care resources to reduce the overall burden of CVD and diabetes, and it focuses on the variation in OECD health systems ability to convert health care inputs (such as expenditure) into health gains.

OBJECTIVES: Many countries are adapting their pharmaceutical reimbursement system, increasingly emphasizing the role of pharmacoeconomics in decision-making. The aim of our study is to analyze European regulatory systems to obtain insight into best practice systems that deliver value for money. METHODS: The analytical Hutton Framework was used for comparing and assessing fourth hurdle drug reimbursement systems in the The Netherlands, Belgium, Sweden, and France. We investigated policy documents, explored literature, and conducted interviews with policymakers and representatives of the pharmaceutical industry. RESULTS: All systems have a centralized decision body, even though the financial responsibility may be regional (Sweden). Only in Sweden, the minister has no role at the individual reimbursement decision level. None of the systems has a fully independent evaluation process and the impact of the systems is mainly assessed on drug expenditure. All countries make efforts to increase transparency. However, in Sweden manufacturers may withdraw their application before the final reimbursement decision, guaranteeing confidentiality at the cost of less transparency. Policies to deal with uncertainty vary per country: financial risk-sharing agreements by price/volume contracts-France-versus outcomes-based agreements for expensive inpatient drugs-the The Netherlands. The actual value of a drug and disease severity is reflected in the level of reimbursement in France and Belgium, whereas in the The Netherlands and Sweden, enlisted drugs are fully reimbursed. All countries attempt to increase the importance of pharmaco- economics in decision-making. However, no country expresses the relative importance of cost-effectiveness compared to other criteria nor applies a strictly defined threshold. CONCLUSIONS: This study reveals that while there is a convergence in scientific evaluation processes, important differences remain between the Dutch, Belgian, Swedish, and French regulatory frameworks. All countries recognize that pharmaco- economics has a place in decision-making on value for money, but for the time being, pharmacoeconomics seems to play a rather undefined role.